Changing or stopping testosterone-lowering medication in men convicted of sexual offenses: clinical evaluation of the COSTLow-R scale.

Background: Men convicted of sexual offenses (MCSO) can be treated with testosterone-lowering medications (TLM) in order to support the control of paraphilic sexual fantasies and to decrease the risk of sexual recidivism. However, due to partly severe side effects, TLM should not be a lifelong treatment.

Aim: The Change or Stop Testosterone-Lowering Medication (COSTLow)-R Scale was developed to assist forensic professionals in deciding on whether to change or stop TLM treatment in MCSO. The current study aimed to evaluate the scale in forensic outpatient aftercare practice.

Methods: The COSTLow-R Scale was applied retrospectively in a forensic-psychiatric outpatient institution in Hesse, Germany, on 72 MCSO. TLM was stopped in 30 patients (41.7%). Moreover, 10 forensic professionals of the institution (23.3%) as well as an experienced working group within the institution focusing on the treatment of MCSO, qualitatively evaluated the COSTLow-R Scale by participating in an open designed survey.

Outcomes: The COSTLow-R Scale ratings as assessed by forensic professionals were collected. In addition, a survey was performed among these professionals about the usefulness of the scale and their practical experiences with it.

Results: TLM stopping decisions were significantly associated with three COSTLow-R Scale items: the compliance for monitoring effects and side effects, the possibility of psychotherapy before TLM treatment, and the therapeutic alliance before starting TLM treatment. In sum, the decision towards stopping TLM was more likely for patients whose compliance was considered higher, and for those who had demonstrated a greater treatment readiness as well as therapeutic alliance before starting TLM. The forensic professionals described the scale as a good and structured tool that displays which aspects are important to consider during TLM treatment decisions.

Clinical implications: The COSTLow-R Scale provides structure to the decision whether to change or stop TLM and should thus be implemented in the forensic treatment process of patients with TLM more frequently.

Strengths & limitations: Although the small sample size limits generalizability of the findings, the present study was conducted directly in a forensic center and, therefore, has high external validity and a strong impact on the life and health of patients treated with TLM.

Conclusion: The results indicate that the COSTLow-R Scale can be a useful instrument facilitating the TLM decision-making process by providing a structured compendium of criteria. Further research is still needed to evaluate the scale and to provide additional evidence for the results of the current study.